Opinion

Censoring B. C.'s health care jewel

Like me, you've probably asked yourself over the years why Canada's health care costs keep rising, seemingly without any hope of relief or controlled mitigation. Is it a wholly natural concomitant of an ageing population and the absence of market discipline in pricing, or are we managing state expenditures in identifiably mistaken ways that can be corrected? I'd say it is mostly the former. But let me tell you a story about something that's happening in B. C. right now.

In 1994, with about a million dollars a year in funding from the B. C. government, the University of British Columbia started an outfit called the Therapeutics Initiative. The Therapeutics Initiative (TI) exists to provide independent, skeptical analyses of clinical data about new health therapies to the medical and pharmaceutical professions --and to the government, which has used TI's advice to decide which drugs its Pharmaceutical Services Division (PSD) should foot the bill for. Much of the TI's job consists of cutting through drug company spin, and it has earned an international reputation for doing so. Its director, Jim Wright, is considered a big wheel in the world of evidence-based medicine (EBM) -- a worldwide cult of grouchy physicians and pharmacists who insist on seeing hard data, and lots of it, before they believe in the power of the latest marketing-driven prescribing fad.

This is not a good way to earn friends. EBM types tend to be harsh critics of not only drug companies, but of fellow practitioners who take from those companies gifts ranging from golf outings and foreign trips to desk sets and expensed luncheons. TI is, frankly and explicitly, very shirty about conflicts of interest in its own work and in the published work of others. Combined with a mastery of the mathematical tools of EBM, that independence has allowed it to discern important facts more clearly and quickly than individual physicians grappling with new scientific literature can hope to.

When the new anti-inflammatory drugs known as COX-2 inhibitors started hitting the market in the late 1990s, doctors couldn't prescribe them fast enough. Confronted with the promise of a new class of drugs for chronic pain, many took the attitude of the slothful journalist: "Too good to check." But the TI did check. As early as February, 2001, in an edition of the group's Therapeutics Letter, you can find it noting that a particular COX-2 inhibitor called Rofecoxib appeared to be associated with a significant, troubling increase in myocardial infarctions.

Rofecoxib's trade name was Vioxx: you might remember it disappearing from the shelves because of those cardiac concerns in 2004, in what was perhaps history's largest-ever voluntary drug recall. TI's early warnings about the Vioxx data, as well as its complaints about the reporting of trial evidence on other COX-2 inhibitors, led to restricted prescribing in B. C. compared with other provinces. That saved lives -- about 500, by one estimate. It saved money, too. Indeed, TI's first-do-no-harm approach to new, oppressively over-marketed drugs has been credited -- by the auditor-general of B. C., among many others -- with keeping overall drug costs much lower in B. C. than elsewhere.

So when the B.C. government launched a task force to review its decision-making process for funding new drugs and devices, TI might have been expected to receive accolades. Unfortunately, the committee was stacked with members who had past and present connections to the drug business, while the EBM community was sidelined. When the task force's report came out in April, it contained a hysterical revenge attack on TI. The world's physicians have praised TI as "independent"; the report calls it "narrow" and "insular" Its resistance to conflicts of interest becomes, in the words of the report, "resistance to meaningful stakeholder engagement." (Note how that buzzword "stakeholder" puts the B. C. taxpayer and the vulnerable patient on an equal footing with drug vendors.)

The Therapeutics Initiative, concludes the report, should be excluded from any role in deciding what the PSD funds. B. C. Health Minister George Abbott has accepted all the recommendations of the task force, and the cutoff of the group's direct provincial funding seems inevitable, since the task force makes that funding contingent on a "reform" that would lead to "expansion of the scope of expertise available to the Initiative" -- which is code for lowering the conflict-of-interest barriers -- and a "reassignment" of its "public education" role -- which is code for shutting up and ceasing to distribute notes on clinical data to the Canadian medical and pharmaceutical professions.

There is no chance the TI will agree to such blackmail. Indeed, the vicious, bizarre task force report only confirms the wisdom of the stringent attitudes it has taken in the past toward drug-industry money and its effects on sound judgment. Unless Mr. Abbott comes to his senses he will be discarding what the citizens of British Columbia ought to regard as a rare jewel.